Failure to Develop Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for residents with complex medical and psychiatric needs. For one resident with multiple diagnoses including dysphagia, pulmonary fibrosis, heart disease, diabetes, Parkinson's disease, and malnutrition, the care plan lacked specific, measurable objectives and did not address individualized interventions for each diagnosis. The plan also failed to include details regarding the resident's NPO (nothing by mouth) status, specific oral care needs, and the speech therapy interventions being provided, despite the resident having a PEG tube and receiving tube feedings. Additionally, the ADL care plan did not specify that the resident was only to receive oral intake during speech therapy sessions, nor did it address oral care needs related to NPO status. In a separate case, the facility did not establish a care plan for another resident with psychiatric diagnoses, omitting necessary interventions to address those needs. These deficiencies were identified through medical record review and staff interviews, and were confirmed with facility leadership. The lack of comprehensive, resident-centered care plans resulted in the failure to address the unique clinical and psychiatric needs of the residents as required.